Editor’s Note: This text is a transcript of the course, Communicating in Difficult Situations, presented by Kelli Marshall, MS, CCC-SLP.
After this course, participants will be able to:
- Identify two key issues that impact emotionally-charged situations.
- Identify two strength-based strategies for communicating more effectively.
- Describe two motivational interviewing strategies for communicating in difficult situations.
The structure for this course is to give a brief introduction and share some key issues that impact emotionally-charged situations that make for difficulty and impact our ability to communicate effectively. Then I will discuss some different considerations and some strategies.
This is such an interesting topic for me to talk about as a speech-language pathologist because we're supposed to be experts at communicating. However, as humans, any time a situation is emotionally charged, we all break down in our communication abilities. Therefore, I want to discuss some ideas for how to navigate that when we find ourselves in these situations. In our role as a therapist, we're working with families and most likely, these families did not have any plan to interact with an SLP or a therapist when planning for having a child or when their family members grow old and may be in a rehab situation.
Interestingly, I was just talking to a therapist in my practice today about thinking about where the family was coming from in an emotionally-charged situation. A lot of times, emotions are driving families when we have conversations like this. Be sure to take into consideration that we are supposed to be operating as a family-centered therapy. As an SLP, occupational therapist, physical therapist, whatever role we are in, our evidence is driving us to play a family-centered role, so hopefully, you are being family-centered and working with families.
Obviously, we also consult with colleagues. In my role with Blue Sparrow, I spend the majority of my time consulting with people who may or may not want me there. For example, I consult with public schools and private agencies across my state and region about making changes. At times, the administrators, principals, or directors of the programs have told their therapists that I'm coming to speak with them and to be ready for that. There are also times when it's like a surprise attack and I just show up out of nowhere. That is not the way I like to enter into a consulting situation. Fortunately, either way, with the strategies that I’m going to discuss in this course, I can typically navigate those situations pretty effectively. There are always times when it doesn't work and doesn't go well for either party, but when I use certain strategies, those negative situations are not very common.
Another important point to make is that anytime we're making recommendations to others, whether it's families, a patient, or our colleagues, we are making a request for somebody to change. We might think that is a small thing and just the nature of what we do, but we have to remember that when we're asking people to make even the slightest change, that can be really hard. Change is not something that anyone likes or does well initially. That takes a lot of consideration as we make recommendations about where people are in the change process.
Considerations for Families
The first area I want to talk about is considerations for families. As I said earlier, this is a personal area for me because not only am I an SLP and consultant, I am a parent of a child with a chronic medical condition, she is profoundly deaf and wears cochlear implants. I am also the daughter of a mom who received speech therapy and the sister of a brother who received speech therapy during some health battles. So, I have not just dealt with therapy providers from the provider standpoint, but also as a family member. I see where we could do better and I see things that we could implement into our daily routines and conversations that can make these things go a lot better.
Grief and Disability
Some things that we can consider early on are grief and disability. I was telling a group recently that we assume grief only goes with death and dying. That is definitely not the case. Grief can go with divorce, with big moves, with a disability, et cetera. One of the first professionals to write a lot about this was Dr. Ken Moses. His article, which is readily available online, was written in the late 1980s and is still so pertinent to what we do today. When you first find out that you're going to be a parent, it generates a lot of different thoughts and feelings about what's to come and what your goals are as a parent and as a family. Then when a disability or a medical fragility or chronic condition occurs, it changes that path and you deal with the same type of grief as when someone dies. Just like grief of death and dying, it does not just go through a process and finish. I'm sure a lot of you can attest to that if you've lost a loved one, and I have gone through that very recently. It is not something that goes away, it kind of ebbs and flows.
I read an article recently about comparing grief to walking in muddy boots. It's very sticky and very heavy at first. But, as it dries, it gets lighter and some of it flakes off. But it has forever changed those boots. So, I want people to understand that there is an emotional piece of grief when dealing with disability as well.
As I mentioned earlier, grief is not linear. It does not start and finish. You go through all of these different feelings on different days and months and years. Also, you can go through any of these feelings at random points throughout the day.
For example, a person can completely deny what is occurring. I know I went through some of that with my daughter. “This can't be happening to me.” “This can't be real.” “I'm just not going to attend to it in the hopes that maybe it'll just go away.”
Anxiety is a big one for me. I'm sure a lot of you have had anxious feelings with new and different situations. I have also dealt with a lot of fear given that my daughter has chronic medical conditions too. I worry about all sorts of things that can happen with her medically.
There is also the guilt of whether or not I am doing enough? Is there something I could be doing differently or more of? There can be depression and a feeling of isolation. Feeling like we're alone in this. There may be feelings of anger. Why am I the one? Why is this happening to me? Why is this happening to her? Why is this happening to our family?
Again, you can bounce around between these different feelings as a parent or family member across a year, across a day, or across an hour. What's really important to know about these feelings is that when we, as professionals, add to that emotional piece and become emotional too, that only adds fuel to that fire of the emotional responses in others. I know that when I'm in an emotional state, I need the other person to be objective, be less emotional, not be accusatory, et cetera. So, keep that in mind as you think about families that you work with as well as colleagues that you work with.
We have no idea what other people are going through in their daily life. We never want to assume that we know other people and the lives they're going through. When people have these emotional responses to things that we ask of them or recommendations that we're making, a good rule of thumb is to think that those emotional responses are coming from a different place. Then, when the situation is less emotionally charged, we can go through some of the strategies that I’m going to discuss later in the course.
Impact of Judgment
Another factor to be thinking about as you talk to families is the impact of your judgment. This is really hard to do because we are human beings. We naturally want to compare things. We automatically want to put things into categories and we compare our lives to other people's lives. That's very natural and I'm not saying that you can ever take that part away. But you can work very effortfully to make sure you're not judging others for where they are, what their life is, or how they're parenting, et cetera. We're in a world with social media and people putting their lives out there on a daily basis makes this extremely hard to do. But at a minimum, as a professional, we need to work very intently on taking judgment out of that.
There are some things that we can do that come from the literature and different areas of evidence. The first one is to think about the fact that you can only control what you can control. If you are thinking, "If the parent would just…," or, "If the family would just…," or, "If that classroom teacher would just do this," then you're trying to control something that someone else has control over. So, control what you can control. Control what can happen in the four walls of your therapy room, classroom, or office, and know that is often enough.
Next, recognize that people are doing the best they can with what they have. In the world we're living in right now, hopefully, we can all understand that we are very much doing the best we can with what we have. I actually had a friend send me a meme the other day that said, "Life is like a helicopter. The problem is I don't know how to operate a helicopter." I think that's the way we have to think about all of this: I don't know how to operate a helicopter. I don't know how to operate life. And neither do the people around you, even the ones who act like they know and they have everything together. That's how people often describe me. “Oh, Kelli has this together. Kelli knows how to do this.” But honestly, I don't know how to operate this helicopter. I don't. I'm just doing the best I can with what I have. Thankfully, in my situation with my daughter and with my other family members, I had a lot of great professionals. At times, I had to talk to them about feeling like I was being judged in certain situations. But in other situations, I had great professionals who gave me that grace and gave me that understanding of, “I'm just doing the best I can in my current situation. I'm doing the best I can with the knowledge I have and the experiences that I have.”
Shortly, I'm going to talk about trigger statements to avoid. These are statements that people say out of the goodness of their heart all the time but they can evoke feelings in others. Remember, when we're evoking feelings and emotions in others with statements like these, that can make for an emotional response and that's what we're trying to avoid.
Finally, we want to think about empathy versus sympathy too.
Trigger statements are statements that I've experienced, I've talked to other family members about, and I've read about in grief literature. These are statements that can really evoke emotional responses in people. I know I'm guilty of saying several of them so please don't feel like, "Uh-oh, I've said all of these things, and now I'm a horrible person." That is not the takeaway at all. The purpose is to start paying attention when you hear these statements and knowing what to do when these statements are made.
The first one is, “Everything happens for a reason.” Who does that help when you say a statement like that? I think a lot of times it helps the person who is saying it. While it might be a very true statement and while it may have been something someone said to you at some point, how does that help? Honestly, in my situation with my daughter, people telling me that her being in this situation is for a reason, makes me have a whole lot of questions. My voice even changes when I think about someone telling me that. I just start to have a lot of comments that I want to say back.
The next statement is really hard. “It made you stronger, you're so strong.” Another statement that kind of goes with this that I hear all the time is, “I don't know how you do it.” I want to say to those people, because I have a very dark sense of humor sometimes, “I do it because I just keep waking up and I'm not sure what my option is but to do it.” So, when people say that to me, I have that emotion with a response. So, my response to you is more likely to be emotionally charged.
Next is, “Every cloud has a silver lining.” I'd really like to know what that silver lining is. “Everyone goes through tough times.” I know this. We all know this. We're not asking to not go through tough times, we just feel like we have been given a whole lot more of them, especially in those moments of taking care of a loved one that's hospitalized or sick or receiving medical services or special services in some way. Sometimes you just feel like, “You know, but not everybody IS going through this.”
The final trigger statement is, “It takes special parents to be the parent of a child with special needs.” I've seen this printed on T-shirts and it’s a very kind thing to think that we were all selected in some way or another by whatever you believe - by biology, by whatever faith base you have - we're all selected in some way to be the parent of the child that we have and that's common knowledge. But I just think that sometimes that statement can trigger a response of, "But I don't know what I'm doing and I don't know why I was selected and I don't feel like this is helping me."
I share with people all the time that when I entered the therapy field, I was not a parent. I was single for probably the first third of my 20 years of experience. I tried to make really good recommendations and to be very understanding of what the role of the parent was like. But then I became a parent and I realized it was a lot harder than I thought it was going to be. For example, babies have to eat not just daily but a lot of times during the day. (I say that as a joke.) I realized that it's hard to keep them clean and it's hard to keep them fed and it's hard to keep them clothed. Then you get into education and parenting is so hard. It's a lot. Then, I became the parent of a child with a special need and that was the biggest jump, to be honest. It made me understand what it was like to feel like we were in survival and to feel like we were just in this panic situation. I felt that when I was first learning about my daughter, and there are occasions when I still feel like that. Sometimes we are in survival mode and somebody's barking orders at me. It is as if the house is on fire. I can't do it. I'm trying to take care of this fire and make sure everybody gets out okay.
The point is that we want to be thinking about that when we're making these recommendations, when we're putting more pressure on families, or when we're not understanding where families are coming from. This is all incredibly difficult. I keep going back to that pediatric framework but I can tell you, I felt it when both my mother and my brother were going through their treatments. Any one little thing could potentially break us. So, you really have to test where people are in this journey and think about these statements.
Another trigger, but is not on the list, is any comparative statement that is made. I have friends who have children with reading challenges or academic challenges, et cetera. Sometimes they will say, "Well, he's really struggling in reading and I know that's nothing like what you have going on." Or, "I know what you are going through is a lot worse." I want to tell them that it's not worse. We're all just different. Kids are kids. There's no need for us to put a better and worse on things. People are people. Everyone has strengths and we can look to those things too.
Empathy versus Sympathy
There is a very popular speaker, a social worker, by the name of Brene Brown, who talks a lot about empathy versus sympathy. This is something we need to be aware of as therapists, so that we are modeling empathy to others versus sympathy. Empathy helps to understand the feelings another person might be having. It fuels that connection between people and offers a kind response. Whereas sympathy is pity. Personally, I cannot tell you one thing that gets me in more of a negative mindset than whenever I feel like somebody is pitying my situation. When they do, I absolutely put up those emotional walls. I will think to myself, “Alright, I will deal with having to be in the presence of you but I'm going to turn off everything else until I can just get out of this situation." This happens because sympathy (i.e., pity) is when people offer a lot of solutions rather than listening to understand.
A lot of times people will say empathy is when someone has fallen into a hole and you say, "Hey, I'm going to get a ladder. I'm going to come down into that hole and I'm going to help you out." Whereas sympathy is walking by the hole, seeing the person down there, and saying, "Ooh, that's a bad situation to be in. You should think about doing this." They are offering a solution to get out. But that's not very helpful and it doesn't feed into a connection with someone else.
You can express empathy, by saying something like, "I see that you're in a bad situation or tough situation. I can help you by…," and give specific examples of how you can help. It can be really hard for parents and families to know what they need, so giving specific examples of how you can be of assistance can be really helpful in these situations.
Another way to express empathy is simply saying, "I'm with you. I'm here. I can listen." Be okay with just listening. “I can't imagine what you're going through but I'm here. I'm here to help.” I have a lot of people who have said to me, "Oh, I know what you're going through." And I'm thinking, "No, you don't. You've never walked in my shoes. You don't know." So, I avoid saying that like the plague. Be careful saying that you know what someone's going through. Instead, say, "I have no idea what you're going through right now."
Some statements to avoid that show sympathy include, “Oh, I'm sorry. It's too bad you're in that situation," or “You just need to do...,” which are not helpful. Before offering a solution, think about asking, "Can I give you an idea that I was thinking of? Are you open to me helping you right now? Or do you just need me to listen?" Sometimes asking those questions first is hard for us to do because we're so used to giving solutions to things.
Any comment that starts with, "At least.." or "At least this didn't happen" is also not helpful. I know with my daughter, I would get comments like, “You know, she has this chronic medical condition, but hey, at least she's here.” I get that. I'm thankful for that. That comment doesn't help me. It puts me in a state of thinking that I'm not thankful for that but, I am. I'm absolutely grateful that she's here. But right now, I'm struggling with where we are and I need support.
Another factor to consider is family capacity. Families have other obligations. To share my family, as an example, when I had my daughter who is medically complex, deaf, wears cochlear implants, (chattiest kid you will ever meet), she is the second of my girls, I also had her sister who was two and a half years older. Her sister is obviously an obligation and a high priority for me as well. I was also dealing with some other medically complex situations in my extended family. I had a marriage. I had a career. All of these things are part of our family capacity, and so adding one more thing can sometimes be the straw that breaks the camel's back. Therefore, we really need to look at the situation not with blinders on, but look at the whole family and the whole situation of what is impacting this family.
When my daughter was dealing with her medical situation, she was really struggling to eat and we needed her to eat. As you are all aware, a big part of health is providing nourishment. So, of course, I was an SLP and I had a lot of occupational therapy friends who were experts in feeding and wanted me to know all of these things to do with feeding. I kept putting them off and putting them off and saying, "Yeah, thanks, I really appreciate that. We'll get to it when we can." At that time, I could not take on one more thing. We were doing medical treatments three to four days a week, and these were full days. So to add one more thing to it was just impossible. To have that expectation, even from friends, that it was something I should do, made some of those grief feelings and guilt surface.
Many families are in survival mode. We're dealing with “the house that's burning down around us” and we are trying to get out of it alive. Survival does not just occur for those in medical situations. Survival occurs for those who might have a loved one with a developmental disability or a physical disability. There are times when you have so much going on that you truly feel like you're just surviving. We all have relationships and finances and jobs and other loved ones and other children and other things going on. Again, we must consider the whole family capacity element when working with families and understanding why they might be emotionally charged coming into situations with you.
Let’s look at some strategies. These strategies are effective not just for working with families but also for working with colleagues. If you're in a school and you're making recommendations, that means you're asking people to change. If you're pushing into classrooms and you're talking to teachers, talking to other members of your related services team, or going to another site and consulting and giving some recommendations to make a change, these strategies are effective for those purposes too. While my examples might be more toward families, know that these are strategies you can use in any situation.
Creating intention is well-researched. If you're an early childhood provider and have done any training in that, there's a lot about creating intention within that as well as many other sciences.
Creating intention is understanding that we, as humans, co-regulate. Rarely do we ever go into a situation where one person is expected to deal with what's going on completely on their own. When we get stressed out or when we are not understanding a situation, we often rely on others. But for our purposes, we're going to talk about what you can do with yourself, first, to make sure you're going into an emotionally-charged situation as an unemotional, objective person.
I like to go through the below list with new therapists when they encounter a difficult situation.
- Am I trying to control the situation?
- What kind of energy or vibe am I bringing to the situation?
- What are my feelings about this client and about this client being in my session/house?
- Do I believe everyone (including myself) is doing the best they can with what they have?
- Am I willing to accept that this is a work in progress?
- What can I do to get myself ready or decompress?
I will ask the therapist questions about why she was feeling the way she was feeling and how she could manage that when she goes back into a situation with a family.
Am I trying to control the situation? That's human nature. Don't kick yourself about feeling this way. We all want some control. But is that the motive you have going in the situation? Are you thinking, “I am going to make the decisions here?” We need to release some of that control when we're working with others, especially when we're working with families. They should have more control than we do as professionals.
Family-centered practice suggests that we're switching from an expert model and we're understanding that families should be at the helm of their treatment and their decisions. So, am I trying to control it? Is that where my motivation is?
What kind of energy am I bringing? Check yourself. Look at what your tone is. What is my body language? What is the tone of this email? We are having to rely so much on virtual means, email, texting, and phone calls without getting to see anybody. We're dealing with "half-face" emotions from masking. I realized that when I'm watching my daughter in her volleyball games, I was way too used to having a mask on and I wasn't aware of my facial expressions when I was courtside and NOT wearing one for that brief period of time. Again, what is the energy and vibe of my facial expressions, tone of voice, and body language? What am I bringing to this situation? I need to get that in check too.
What are my feelings about the client? There are going to be clients who we have less of a connection with and maybe bring about different feelings in us that are not as positive. How can we be aware of that and how can we change that?
Do I truly believe that everyone is doing the best they can with what they have? Do I believe that about myself? I know I'm my own worst critic. Do I believe that everyone out there is doing the best they can with what they have? When you truly start to believe that, it really is a big release. It takes a lot of weight and pressure off your shoulders when you think, "You know what? They're just doing the best they can with what they have. I know that I'm here to help them and support them." That's a lot easier than thinking a lot of judgment and “if they would just,” and “I don't like that I'm put in this situation” or whatever it is. So, do I really, really believe that?
Am I willing to accept that we're a work in progress? We are a process in motion. We're trying to make changes and things will change over time. Am I willing to accept that not everything has to occur right here, right now today?
What can I do to get myself ready or to decompress? These are all of those different things that you might be doing, and not even know that you do to decompress. For example, I like a warm beverage to kind of bring me back to that warmth and centeredness. I like to listen to music. Some people like to do mindfulness and meditation strategies. Some people like to read poetry or repeat mantras back to themselves. I have one posted on my wall that I'm trying to live by because I tend to be a perfectionist and that usually brings me to a place of wanting to control situations. But I'm trying to remind myself often that “perfect is the enemy of good.”
A lot of people have things that they do when they're trying to get ready to decompress. They'll recite a Bible verse, a quote, a literary quote, something like that. Think about what things center you and bring you back to feeling ready to talk to other people. We are going to have to enter these emotionally-charged situations as therapists. It's going to happen, it's unavoidable. We shouldn't want to avoid it, it's necessary for helping people to make a change and to get through difficult situations.
A strength-based approach is not new even though many of us are still struggling to adapt to it because of how we were taught in school. This is a movement away from a deficit-based approach that looks at those things we need to fix in other people. A strength-based approach suggests that, in order to make any change, we have to know what the strengths are for ourselves and others. We use those strengths to make changes and address difficulties and deficits.
Because standardized testing is organized to focus on deficits, it is natural for us, as therapists, to focus on what our clients can’t do. When I go into a consultation, people often want to tell me what others are not doing well. When I say, "Tell me something they do well. Tell me something that you think is a strength of theirs." That's a lot harder for people to focus on. We have to go into this approach with an understanding that everyone has strengths and abilities. We all have unique things within ourselves that we're good at.
Let’s say you have a patient who's just had a TBI or a stroke and they're not coherent enough to respond to us so we're having a hard time knowing what their individual strengths are. We need to start looking around them to determine their strengths. Do they have family support? Do they have a certain type of support around them? We need to look at that and say, "Okay, I see these strengths around us. These are the things we can use to address those deficits or weaknesses." We can change and develop from those strengths. Therefore, it's really important that we are aware of that and challenge ourselves to find the strengths.
If we identify X number of weaknesses on a battery of tests or an intake form, then we can identify a large number of strengths that are available to us as well. We cannot address those weaknesses without them, and the literature is really supporting that. It is a shift in mindset and can evoke some feelings in therapists of, "Wait a minute, I've always relied on the test to identify weaknesses so I'm going to address those weaknesses." Is that something that you're doing? Our literature is telling us not to just focus on deficits.
We also want to be sure to recognize that the problem is the problem. The client is not the problem. Whatever their behaviors are, whatever their deficits are, whatever the challenges are, that's not who they are. It is just a problem. It's just an issue to consider. We want to be very objective with that and think about how we can separate the person from the problem in order to address it. If we don’t separate the person from the problem, that is when we end up with those emotions that we discussed earlier. When our client and their family know that we're focusing on strengths, they can more easily see them too. You're helping them out of grief and you're helping them see, "Okay, so we have this strength that we can use, and we have this skill that we can use to work on things.” As a result, the family is better able to cope with the situation and see the light too. You can get so bogged down by everything that's going wrong that it's really hard to see those things as the caregiver, as well.
As I have said, my daughter is profoundly deaf and that's typically what is brought up about her; this deficit that we all know about. So, I started taking note of what it makes me feel like when that's the first thing brought up by a professional. In my wrong sense of humor, there are times I want to say to them, "What? She's deaf? What did you do?" And that reaction in me is because I know this about my daughter. I know this because I deal with it every day and I have for a long time. It is so much better when people bring up her strengths.
One of the best ways to start off on the right foot is by knowing the strengths of your clients and the families that support them. We want to encourage and empower them. Know the strengths of your team, the classroom teachers, other therapists, the doctors and nurses that you work with. Know what they are all good at so that when you want to make a change, you can utilize their strengths to address the weaknesses. This does require you to be very observant and to really get to know the people around you, but if you do these things, it leads to such a better atmosphere and a better understanding of when and how you make recommendations. As professionals, we are very skilled at making recommendations and individualizing therapy recommendations for our clients, but we also need to individualize the recommendations we're making to each other.
I am a very process-oriented person. That is a strength of mine. When a very creative person approaches me with an idea, that can immediately throw me into a tizzy because I have no idea what to do. I commend those who are creative, you're amazing people. I am not like that.
My business partner is very creative. Over time, she has figured out how to approach me with an idea. She will say, "Kelli, I was thinking of how you always have a great way of putting things into a process and I have this idea that I think you could help me with. Here's the idea and here are a couple of things I'm trying to figure out." She comes to me with the problems and knows that I can develop a process for them because she knows me well. In turn, I will say to her, "I see this problem, but I have no idea what solution we could do for it. I was thinking with your creative mind, maybe you could help me come up with something we could do to address this problem." A lot of times she'll come up with a solution to it and then I come up with how we can execute that solution. We know each other so well and how our brains work, and we can help each other out because of our different strengths.
Motivating Change via Motivational Interviewing (MI)
We have talked a lot about motivating change. When we are asking clients, families, and colleagues to make a change, that is considered to be a recommendation. At the bottom of every evaluation, we write our recommended plan. Goals are also a recommendation to make a change. Recognize that you're asking people to change all the time, and that is hard.
Motivational interviewing is used for going through these difficult situations. It was developed from mental health and addiction. Within the framework of addiction, people are trying to make a change to not use whatever substance is there. The idea of motivational interviewing is to help people explore why they want to make the change and where they are in the change process in order to resolve ambivalence. When we ask people to make a change, we can’t just say, "Hey, make this change." That doesn’t simply change that habit. There are a lot of different steps required to make that change happen. Therefore, we need to be skilled at identifying where people are in their change and that's where motivational interviewing can come into play.
Motivational interviewing is very collaborative and person-centered, which should not be hard for us. We know that we are client-centered and family-centered in our focuses, and we try to guide people through how to make the change. We don’t simply tell a person that they need to practice a skill. We guide them through making the change of practicing that skill. Hopefully, that makes sense. Then we become the agent of change by partnering with the client, the family, or our colleague, and helping them accept what has to change. We have to model compassion and empathy in order to evoke that change.
Something that I notice in people when they're contemplating change is that they think about the reasons why they can't do something versus the reasons why they can do something. That's a really big indicator of where people are in their change process.
Principles of Motivational Interviewing
Express Empathy to Build Rapport. The principles of motivational interviewing have a foundation in empathy and building rapport with others. Some people think that building rapport can be very time-consuming, and, of course, that will depend on the situation. Building rapport is very individualized, but it is an opportunity to take off that therapy hat and say, "I see that I'm a human and you're a human and we should get to know each other a little bit better. I need to understand your situation a little bit better before I can jump into solutions." As I said earlier when we were talking about empathy versus sympathy, sympathy is that solution-driven place, and I think that's where we live a lot of times as therapists because that's what we were taught to do. “Here's the problem and here's the solution.” But you have to take the time to get to know people and to build rapport because they don't know what you do. More often than not, when somebody meets you as a speech therapist, they have no idea what that means and what you do. You're going to have to build rapport so that they can trust who you are in that part of the process.
Develop Discrepancy by Listing Pros and Cons. This is developing what would happen if the client, family, or colleague followed the recommendation I'm making. What would happen if we didn't? What would happen if we followed a different plan? I like to write a lot of things down. Try to make things as visual as you can because what we say, that auditory message, is transient. What we put down on paper or in a PowerPoint is static and you can refer back to it. Listing the pros and cons visually can be really helpful for people to see what choices they have to make.
Roll with Resistance by Respecting Autonomy. Resistance is a natural part of change. But all the while, respect autonomy. Everybody has the right to make the decision that is best for them and their loved ones. This goes back to that judgment piece. It might not be the same decision that you make and you're going to have to be okay with that. One of our ethical principles is that we respect autonomy in others, but it is also a human principle that we respect autonomy in others. Everybody has the right to say, "That's really not the change for us." Or, "That's not the change right now for us." We should not judge that decision and we should not have negative feelings toward others about that decision.
People deserve autonomy. No one would want their choice taken away from themselves or a loved one. I often put it back on the providers. When I hear people really resisting change and maybe getting angry with me, I say, "It really comes back to, are you a parent? Have you ever had a loved one in the hospital? Have you ever been in the hospital? Would you want someone to take those decisions away from you? Those choices are very personal and they belong to you." We need to respect that everybody has that ability and they might be resistant at times. They might resist you and say, "Nope, I’m not doing your plan." Then a couple of days, weeks, or months later, once they've had some time to think about it, they may say, “I've been thinking about it. I've been sitting on that idea for a while and I think I'm ready to talk about it. I think I'm ready to make that specific change.”
Again, know that resistance is just a part of the process. It's okay if people resist what change you want to make right then. Trying to push through it is usually not going to end well. It is better to say, "Okay, I see resistance right now. That's okay, that's a natural part of this process."
Support Self-Efficacy. Support self-efficacy by communicating that the person/entity is capable of change. Here is another personal example. When I was a parent of my firstborn who did not have a lot of complex needs, I was also a therapist at that time. The majority of my caseload was working with children with autism. Many parents would say to me, "You would be a better parent to them than I am. You would be better at this than I am." At that time, I thought it was such a foreign thought that I would be better just because I have a skillset or a degree that makes me know more about this general population. That's such an interesting thought. I would always try to tell them, "No, no, you're meant for this kid. You are their parent. You are the one." I would really try to reinforce that.
As it turns out, that was a good thing to do. However, these types of comments became less foreign to me when I was the parent of a child with special needs, and that was really evident when Libby lost her hearing. It was an acquired hearing loss within her medical treatments. She lost her hearing and I had so many people tell me, "She's so lucky to have an SLP as a mom. You know sign language. You're going to be great." But I always thought to myself, “Sure, I took a graduate-level sign language course. I remember two signs – ‘lion’ and ‘dancing’. Those do not come up very often in everyday life. I felt like I was letting down the whole SLP profession with my limited recall of sign language and I was letting down my daughter. She had an SLP and an audiologist at the time, and I remember thinking they would be better for her than I could be. Thankfully, I had people on my therapy team and people on our medical team that knew how to support self-efficacy. They would constantly reinforce, "No, you're the mom for her and you're a great mom for her. Look at all of these things that you can do for her. Look at all of these ways that you're going to be able to help her through her life." They were great at reinforcing me and encouraging me that I was capable of doing these things. Therefore, don't discount yourself or discount saying encouraging words to people. It can really be the thing that helps them to keep moving forward.
Stages of Change
Change, just like grief, does not just start and end. People will bounce around within these stages of change day by day, hour by hour, et cetera. As I mentioned earlier, motivational interviewing began in the addiction literature but has since been adopted by health and wellness in areas such as weight loss and overall wellness strategies. It has been adopted by business principles and business backgrounds, and in our field as well. Motivational interviewing is a great way for us to determine if people are ready to make a change or where they are in that process.
The beginning stage is pre-contemplation which is when a person knows that something is going on. I may be aware of it, I may be in denial, but I have no intention to change at all.
As a therapist, you need to be planting that seed. You're not saying, "Hey, here's a problem." But you may be asking more questions such as, "Tell me about what you see." "Tell me about what brings you here today." "Tell me why your loved one might need me as a therapy provider. What do you think that need is?" Honestly, the client and/or family may have no awareness. They may be in such a deep emotional state that they don't even know why you are there. You need to educate and inform them about why you're there.
Contemplation is the next stage and is when we know that there are some issues or something that we might need to change. You can even think about this as making a recommendation to your colleague such as, "Hey, I think we need to add this strategy, or I think we need to change this goal." This is the stage where people are aware that a change needs to occur and are starting to really think about it. However, they haven't made any commitment or any plans to act on it.
This is where you, as the therapist or as the colleague, are going to raise awareness. "I really think we need to consider this issue that's come up for Johnny." Or talking to parents and saying, "We've been talking a lot about the struggles you're having at home with this particular situation. I'm seeing those struggles in the therapy session too and I just want to see where we are with addressing that? How do you feel about starting to directly address that situation?" You're raising the awareness and giving specific and reasonable concerns about why that needs to be addressed.
Preparation is the next phase. At this stage, we know that we have an issue and it needs to change. We're starting to make some small changes. This might be where you start to make a plan of action about it. We're being very encouraging about change and we're supporting that change process. We know that there is a lot to address, we have a specific systematic plan in place, and we know who is assigned what role in this process.
I go through all of these stages and think about when I've made big changes. We all know that after the first of the year, a lot of people make weight loss or diet plan changes. The preparation stage is similar to that meal prep point where you've bought all the containers and all of your grilled chicken and veggies. That's the preparation stage. You have all the stuff and you're starting to do your cooking.
In the therapy mindset, you're making your plans, creating visual supports, mapping out who's responsible for what roles, and writing those things down with your team. You're preparing for it.
The next stage is to take action. You can say to the family or client, "Okay, today's the day we make a change." Or, "What date are we going to make the change?"
The last stage is maintenance. At the maintenance point, you're trying to prevent resistance and ambivalence. Back to our previous example about a new weight loss program, this is the point when I open the fridge door and I see those meal prep containers, and say, "Ugh, I just want fast food." Or, "I just want to eat cookies for lunch." Or, "I do not want this meal prep." That's the ambivalence, that's the resistance to that kind of framework.
In therapy, this is when you get to work on Monday because you're going to make a big change and put up all these visual schedules or take data on everything. But, then, you start thinking, "Oh my gosh, we have a fire drill and an assembly today and I just can't with the visuals and the data collection." But we can't keep making excuses about making a change so we have to roll with it.
When you're supporting somebody else who’s making a change, your goal is to help them identify those moments of ambivalence or support them through those moments and say, "I know these changes are hard," or, "I never want to make a change on a Monday, but here we are. We're going to have another Monday anyway so we might as well do it today." In these moments, sometimes I'm not above bringing treats, or some sort of reinforcement, to my colleagues and to my clients to help encourage them to make changes too. I work with pediatrics and a lot of children have autism. Reinforcers are a big thing in that area of our profession. I make sure I have all my reinforcers in place. I already told you what my reinforcer is Diet Dr. Pepper. If you came in a fountain Diet Dr. Pepper on a day that I'm showing you some resistance and ambivalence, I am probably going to have a little more encouragement and motivation to keep pushing forward to make this change that we've decided to make.
Remember, you do not move through these stages sequentially most of the time. You might move through the first three sequentially and then go back to the first one again and think, "Oh, I'm not ready to make a change. Eating all this grilled chicken and vegetables is ridiculous." You might bounce around in the stages. Motivational interviewing refers to it as a spiral. There's a lot of ambivalence that has to occur before you get into true maintenance of the skill.
Before getting into the conversation, it's a good idea to think about the following:
- Open the conversation
- Ask permission
- Open-ended questions
- Reflective listening
- Ask about the next step
- Show appreciation
- Voice confidence
If these strategies are new to you, write them down or make a script so that you can ask yourself, “Did I open the conversation? Is there a way I can ask an open-ended question?”
Opening the Conversation
This is a great thing to do. Like I said earlier, you might have clients that don't have any idea why they're there. We can open the conversation with, “What brings you here today?” or “Tell me a little bit about why you think your loved one would need a speech therapist. Tell me what you know about speech therapy." Maybe not in such a quizzing way but saying, "I'm a speech therapist and these are some of the things I do. Are there any of those things that sound like something your loved one would benefit from?"
Let’s say that I notice a client is struggling with a certain skill. Augmentative communication comes up a lot in my practice. For example, I have a five-year-old who's not talking and I have to start bringing up the idea of using an augmentative form of communication. A lot of times, that’s a really hard thing for parents to hear. I may say to them, "I noticed that Johnny hasn't made a lot of strides in verbal communication. He's not really speaking a lot yet, but we know he has so much to say. He tells us by taking us to it, showing us what he likes, or spending time with the people or the things that he likes. Could we maybe start a conversation about a different way to communicate?" Posing it as a question gives a little bit of control back to the client or family.
You can do this with your colleagues too. As a consultant, I go into classrooms or different places all the time, and after doing this so many times I can immediately see some things that need to change. But I don’t go in with that sympathy mindset or a solution mindset. I have to, first, get to know the situation and build rapport. I might say, "Hey, I'm here for ‘X’ reason. Tell me about what you're struggling with in the classroom,” or “Tell me what you're struggling with at work." Then if I notice a solution, I say, “I have an idea that I'm thinking about. Is it okay if we talk about that?” Or, “Are you ready to talk about that right now?" I want to give them the chance to say whether or not they are ready because I don't know their life. I don't know what happened before I got there. It might not be the best day to have this conversation. It might be the best day for me, but that doesn't mean it's the best day for the. So, ask for permission.
It changed my life when I started realizing how many yes/no questions or closed-ended questions I was asking people and I changed those into open-ended questions. When my daughter was receiving speech therapy, I was often asked, "Did you do the homework?" As a parent, I can tell you that question elicits emotions and guilt because the answer is a pass/fail. I always felt like If I did the homework then I'm a good parent. If I didn't do it, I probably stink at this.
That's the emotion that the question evoked in me and I've talked to a lot of parents and I've read a lot of family-centered articles that say the same. “If I say yes then I'm doing good. If I say no then I'm doing bad.” So, of course, I would always answer yes, and a lot of times I was lying because I could not deal with whatever their response was going to be. Here I am, not only a mom, but a mom who has the same background as a therapist, and I didn't do what I know helps children to progress faster. So, I lied because of the feeling of being a failure.
I remember one day when I was really in a survival place and I had just gone through a big medical situation with my daughter. We ended up at therapy either the same day or the next day, and the speech therapist says, "Did you do the homework?" Well, “emotionally-charged Kelli” came out and I said, "Nope, and guess what? I never have or I rarely, rarely have. In fact, that book that you wanted me to read to my daughter, I've had to order three times from Amazon because one time, I’m pretty sure she threw it out the window, and another time coffee spilled all over it. So, this isn't even the original book you sent home with me. So there. You do what you need to do. Take her away, report us to whatever authorities you want, I know I'm bad."
That was my emotional-charged response. The therapist was so awesome because she had some of these strategies and she said to me, "You know, if you're not able to do the work at home that we have talked about, that’s ok. I didn't ask you if you wanted to do the homework, if it fit your life, or if it was functional and helpful to you. So that's on me. I need to think better." The therapist said, "I need to think better about what I'm recommending and I need to get more of your input on what I'm recommending for you guys to do at home." I remember feeling such a release and so much relief of, "That's right, it's on you and not on me for once." But I also felt like somebody else was taking some responsibility in all of this because it is really, really hard as a parent to carry so much. We know all parents are carrying a lot, but every little extra thing that's added is more. I mean, that's a pretty easy equation there.
The SLP started using open-ended questions and instead of saying, "Did you do the homework," she would say, "Kelli, tell me about how Libby made choices this week." Or, "Tell me about how she's communicating with you. Do you feel like she's still communicating in gestures or gestures and words or more words? Tell me about that." She started to give me those open-ended questions and I started doing that with my own clients. I get so much more information from that than a yes/no or a pass/fail question.
Open-ended questions have totally changed me with colleagues too. Saying, "Tell me about the classroom. Tell me about the student you're working with. Tell me about the client you're working with," gives you so much more information than saying, "Did you give this test or did you use this strategy or did you use this support?" You get so much more from the open-ended questions.
This occurs at that rapport-building part of the conversation and we're saying, "I know this situation is tough for all of us. I know that you have a lot on your plate as a parent." Or, "I know that you have a lot on your plate as a teacher of 28 students during a pandemic. I know this is really, really tough. But I think we can do some things. I think that we are ready for change." Or, "I think we are all ready to take on this task."
You also want to practice reflective listening, which is going in with the intent to understand versus the intent to respond. For SLPs, this is tough because we like to talk. But in reflective listening, when you're asking those open-ended questions, instead of constantly thinking about what solution you're going to provide to all of these problems, you're focusing on just listening.
A strategy that I use is to repeat three things back to the person that I heard them say. I'm working the whole time on listening intently so that I can say back to them some of what they said to me. If a teacher is telling me how difficult it is to have Johnny in class or a mom is telling me how difficult their life is due to something, can I repeat some of that back to them? That's really reflective listening.
Then, you want to summarize what they are saying. For example, "I hear that home is hard because there are no words, and when Johnny wants something he is starting to hurt himself or others or destroy the property. I'm hearing that you would really like some strategies for how we can make that better, am I right?" You are clarifying, summarizing, and making sure that you are understanding what's going on. Summarizing can be done with colleagues and with families.
Then ask, "What do you think the next step would be?" Do they have any input? Sometimes you're going to get, "I don't know, that's why you're here." Or, "I don’t know, that's why we're at speech therapy." Then you say, "Oh, that's great. I have one or two suggestions." Again, you can go back to asking permission, "Are you ready to hear some of those suggestions?"
I tell parents, families, students, clients, and colleagues, thank you in every single conversation.
I actually had a therapist come to me this morning who was struggling with a family that she was working with. I thanked her for coming to me and trusting me to help her navigate a situation. It can give people an understanding that you really want to be there to help, that is your motive and your intention. Saying thank you can go a long way.
Say, "I really think that we're all ready. We're all on the same page and we are understanding each other's roles. I think we're ready to start targeting this goal or start making this change."
The first tip that I am really passionate about is to slow down. I am often told to slow down and that I talk too fast. I wish I could practice that as much as I preach it, but slow down, take your time, and don't be afraid of pauses and quiet moments. This is something that I struggle with personally and professionally.
Avoid overload. If you're thinking of 19 solutions or 35 goals that you could work on with a client, then you need to scale that down. We need to avoid overload for ourselves, for the client, for the team, for the family, et cetera.
I mentioned earlier to use visuals. Write things down whenever you can. Share it with everybody. I love the big Post-It boards. I love typing on something when there's a visual. Zoom is great for screen sharing a Google Sheet or a document. You can type notes, ideas, goals, etc. and everyone can see the document as ideas are being discussed.
Offer choices for start time. “Do you want to start this week, next week, two weeks?” “When do we want to start this plan?” With parents, maybe you're recommending to practice a certain skill at home. “Do you want to start that practice now? Do you want to start that just on your own? Do you want me to give you a worksheet and some guidance or some specific ways to target that?” Give choices whenever you can.
Talk about what other people do. People don't know what they don't know. You can say to a parent, "We can target X this way," and they may not understand what that means. Instead, you could say, "I've worked with other families and we've utilized this strategy." Or, "I've worked with other clients and we've used this strategy and it's been really helpful. You know, there's also this way that we could do it." Talking about other situations and experiences that you have had can be really helpful.
Assumptions to Avoid
The first assumption to avoid is that people want to change or ought to change. Many families are in survival mode and just can't change. It has no reflection on you and how wonderful you are as a therapist. We just can't.
Also, there are some families whose health or diagnosis is just not a primary motivator. We need to be okay with that. Release that need for everybody to be like you or have the same priorities, passion, and motivation as you. We’re living in a world that, hopefully, is getting to be more accepting of differences and understand that neurodiversity is just as important as any other type of diversity. Health and diagnosis do not have to be prime motivators for change.
Furthermore, if the person doesn't want to change that doesn’t mean they fail. Similar to the yes/no or closed-ended questions, assuming a person wants to change evokes in many people that feeling of, “If I didn't do it, I fail.” It also makes us, as professionals, feel that way too. But we need to let go of that. If they're not ready for it, that's okay. Remember, resistance is a normal part of changing.
Don’t assume that people are motivated to change or not motivated to change. Sometimes it's the timing. Sometimes it's the grief process. Sometimes it's just the stage of change.
Avoid assuming that the person has to change right now or that a tough approach is the right approach. That is NOT the best approach. I can promise you that. Don't give those ultimatums or threats. Don’t say to the client or family, “If you don't do it then you can't return here.” Or, “He can't be here.” Or “You can't get this service.” That will never get the response that you're hoping to get.
The last tip refers back to that expert model. We might be an expert in this field but that doesn't mean others have to follow what we do. Our sciences are really pushing us to be collaborative and to be family-centered. We're a voice in that but we are not the voice in that.
Signs of Resistance
There are some signs of resistance to be aware of. Anytime colleagues, families, or clients start to argue with you, interrupt you, deny that things occurred a certain way, ignore what you say, or ignore you during a meeting, those are all signs of resistance. When we observe those behaviors, we don't have to call people out, but we can say, "I think we've done what we can do today. When are we all willing to come back to the table and talk about this?" Another example is if it's a therapy session and you know you're going to see them the next day or the next week, you can say, "I think that's a good place for us to pause on this piece today. We can get back to it (tomorrow)." It does take really good rapport with someone to push through this type of resistance.
Another type of resistance I see a lot right now is crowdsourcing of ideas. This is when people come to you for input and when they don't get the response they want from you, they go to another person and another person and another person until they finally hear what they want to hear. That can also be a sign of resistance.
However, these are very common, and really, the best recommendation is to just hit the pause button and come back to it. There may be a handful of people that I can push through when either I'm resisting them or they're resisting me with these things. We can actually push through and continue to make those changes. But with most people, I don't have that level of rapport to push through the resistance. So, that is the time to hit the pause button. We can go back to it later.
Tips for Meeting with Families
When meeting with families, be sure to start with a positive statement. For example, "I think it's so great how Johnny always has family here or that you guys are so involved." Again, with my daughter, don’t start with, "She's deaf," but start with, "Libby is the chattiest, most sure of what she wants, and will get what she wants of anyone in our class. She is maybe the biggest lover of glitter and unicorns and she also happens to be deaf." We want to use those strengths to address those weaknesses.
Don't be immediately dismissive of family requests. They might seem like pie in the sky to you. But, again, a lot of times, this is the first time this family has been in this situation and they don't know. Instead, maybe ask questions. A question I get a lot working with students in the schools or a request that we get a lot as a team is that the parents want a paraprofessional. Instead of saying to them, "We don't do that unless this process is done," I usually ask why by saying, "How do you think that paraprofessional will help your child? Let's troubleshoot through that." Then give them some pros and cons of having a paraprofessional, a teacher's aide, or a private aide.
Be sure to ask what parents want, what they need, and what their goals are as many times as you possibly can. I know IEPs and the schools are set up to give you moments of that. But try to ask it as often as you can in meetings, in hospitals, and in other outpatient settings, not just during the initial evaluation, intake and periodic progress. Are these goals leading to changes at home? Are there other things I could be doing to support you?
Questions and Answers
I have a coworker who is struggling to accept that families are not required to follow suggestions for strategies and referrals. He seems to feel that because he is the therapist, the family must make appointments with other professionals he recommends and demonstrate 100% compliance with the home program, such as insisting the child dress themselves 100% of the time by a certain date. This results in adversarial relationships and some parents simply stop coming to any therapy. How can I share your advice so that he can possibly understand that not all families can or will implement every suggestion or program?
I feel like I've definitely worked with people like this. Something I go back to is my schooling. We have to remember that your coworker is also going to have to experience a change. We're asking him to change too from, maybe, learning in more of an expert-model mindset to going to more of a family-centered mindset. Things that we've done in my practice to address that is to look at the family-centered literature and to look at the literature on grief. And, we want to bring it up in a very objective way, "We're going to do a journal reading or we're going to try to challenge our minds to do a different type of practice." Then if that doesn't seem to help him identify himself, then maybe also look at those motivational interviewing strategies and plan a conversation. It's really hard and I hear all the time, "But I don't like conflict." No one likes conflict or confrontation. But some of us feel a little more comfortable in it than others and that's where I am.
But maybe you can go through this in an indirect way by bringing up the literature or talking about doing a lit review as a team within the family-centered practice, etc. If that doesn't seem to be working, then it might be time to have a conversation. If you're not in a leadership role, make sure you're following that chain of command. Bring it up to leadership. When we are requiring someone to do those recommendations, we're not allowing for client autonomy to occur. So, think about that and bring it up to leadership regarding how are we going to resolve this issue? That would be how I would respond.
How do you use the principles when you are legitimately concerned that the family's lack of follow-through constitutes neglect or that a parent is overwhelmed and cannot follow through, but the child is suffering physically or mentally because of that?
It's good to have connections with child welfare, or whatever agency/entity is in your location. You want to know what truly constitutes neglect and what constitutes the child being in danger and jeopardy. So, talking that out, not necessarily making a formal complaint or anything like that, but just saying, “These are things that I am, you seeing, and does this constitute that?” Because sometimes we can be in a frame of mind that this person’s life is not like the life I lead.
I will share my own situation. Right before a big medical procedure for my daughter, someone called social work on me because I was very emotional. And I think that it's just understanding that emotions are big and hard for a lot of us that are dealing with challenges. Some of us have more ability within resiliency to deal with that than others, so resiliency literature is really good to look into to understand how you can support people that aren't as resilient in those situations. But if it is truly a neglect situation, then it is our responsibility, as providers, to report things like that. If not, I think we have to really open up conversations in an empathetic way and say, “These are some concerns I have, and these are ways I can help you. What can I do? What can we connect you with? How can we support you?” Because more often than not, the best place for a child is with their parents and hopefully we can facilitate that so it could stay that way.
If continued resistance occurs, what might be some options?
With the speech therapist that I worked with, we were really working with my daughter with her hearing loss on making verbal choices or making choices without it being her behavior. The SLP was sending home a lot of books and worksheets and figures and all these great, wonderful speech path things. I'm not kidding when I say that all these materials were literally getting lost in the floorboards of our car and I purchased "The Icky Sticky Frog" multiple times from Amazon. I can remember it was that book. The SLP had to remind me that I could give choices at mealtime and I could give choices at bath time and I could give choices during dressing. I forgot about all of those naturally occurring moments when we could practice these skills. As a parent, I couldn't think like a therapist. I could think only as a parent.
Even if you think somebody would know those things, sometimes you have to help them. I give that recommendation to people all the time. How was I not thinking of that? So, it was just baffling to me when she said those things. I thought, "Oh my gosh, how did I not think about that?" So, as much as you can put it into natural life and not make it something extra that they have to do, that is a huge help for people.
Also, keep it small. Don't make recommendations that have to be seven steps. Think about one small skill that can be worked on this week. “Three times this week you are going to do X.” You know, three times is way more than what they were doing it. Then next week, maybe we can say, "What do you think about making it five times that we work on choices this week?" As they get more comfortable with it and know how they can implement it, add more and more.
Do you ever collaborate with a counselor to ensure that you support emotionally-complicated patients or clients?
I do. We have had behavioral health as part of our practice at times, and I also have a lot of colleagues in the field. Again, it’s sticky sometimes because if I identify that they have very natural reactions to the emotional situation, then I just try to wade through that with them. But if it starts to look like they're stuck or they're really dealing with emotions that are outside of my scope and outside of where I can support them, then I will absolutely bring in a behavioral health professional. I would probably ask the client or the family for permission. Such as, "I noticed that there are a lot of times that this gets really tough and then emotionally it's weighing on you. Would you ever be interested in connecting with a counselor? Would you ever be interested in me contacting someone so that they can contact you?" Saying, "Would you like me to help you with that," can really help the person because asking for help the first time is oftentimes the hardest. But, yes, I've definitely done that in the schools and in my own private practice. I'm a huge advocate for collaborating. We cannot do this on our own. We have to reach out to all of these different disciplines and look at it through different lenses in order to best support our clients.
Bailey, R. A. (2004). Conscious discipline. Loving Guidance.
Brown, B. (2012). The Power of Vulnerability: Teachings on authenticity, connection and courage.
Moses, K. (1987). The Impact of Childhood Disability: The parent’s struggle. WAYS magazine, 1, 6-10.
SeekFreaks: 3 Steps to a Strengths-based OT, PT & SLP Practice (Retrieved from: https://www.seekfreaks.com/index.php/2017/04/18/3-steps-to-a-strengths-based-practice-2/)
State of Victoria, Department of Education and Early Childhood Development (2012). Retrieved from: www.education.vic.gov.au/earlylearning/transitionsschool
Understanding motivational interviewing. Understanding Motivational Interviewing | Motivational Interviewing Network of Trainers (MINT). (n.d.). Retrieved December 14, 2021, from https://motivationalinterviewing.org/understanding-motivational-interviewing
Marshall, K. (2022). Communicating in Difficult Situations. SpeechPathology.com. Article 20514. Available at www.speechpathology.com